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Morbidity and Mortality Conference. Feb 13, 2002 Martin S. Rhee, MD. History of Present Illness. 54 year old female with ESRD presented with mental status changes Headache, neck discomfort x hours Confusion Fevers. Past Medical History. ESRD 2 ° to DM, HTN Hemodialysis

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Morbidity and Mortality Conference

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Morbidity and Mortality Conference

Feb 13, 2002

Martin S. Rhee, MD


History of Present Illness

54 year old female with ESRD presented with mental status changes

  • Headache, neck discomfort x hours

  • Confusion

  • Fevers


Past Medical History

  • ESRD

    • 2° to DM, HTN

    • Hemodialysis

  • DM II (non-insulin dependent)

  • HTN

  • PVD

    • s/p R above knee amputation after failed R femoral popliteal bypass (7 months prior)

  • Osteomyelitis of R stump post AKA


Medications

  • Nephrocaps 1 tab PO qd

  • Doxepin PO qid prn

  • OCP(estradiol/progestin)

    ADR

  • Cefazolin (hives)

  • Morphine sulfate (nausea)


Social History

  • Married

  • Lived with husband

  • Clerk

  • Cig: 2 ppd for 30yrs

  • EtOH: rarely


Physical Examination

  • 100.9 102 (BP not recorded)

  • Gen: Somnolent but arousable, oriented

  • HEENT: PERRL, EOMI, OP-dry, clear

  • Neck-Discomfort with flexion, JVP-7cm, no LAD

  • Cor: RRR, normal S1/S2, no M/R/G

  • Lung: CTA bilaterally

  • Abd: Active BS, soft, nontender, no HSM,

  • Ext: No C/C/E

  • Neuro: CN-grossly intact, Motor-5/5 in UE/LE, Sensory-intact to light touch


Laboratory Data

13.1

128

89

55

291

19.7

157

8.6

40.5

4.8

23

PTT: 40.6 PT: 11.7 INR: 1.1

CK: 160 CKMB: 14.92(<5.0) Tn: 0.13(<1.50)

UA: Negative

No initial CXR

EKG(show)


Admission EKG


Initial Management

  • Fever & Mental Status Changes

    • Empiric levofloxacin given

    • Meningitis?, line infection?, pneumonia?, UTI?, infective endocarditis?, osteomyelitis?

    • Await for blood culture results

    • LP

    • Line removal if needed

  • Cardiac

    • Acute coronary syndrome

    • ASA, heparin, beta blocker

    • No thrombolytics


HD #1-2

  • Hypotensive episode (SBP 79)

    • IV dopamine, IV dobutamine

    • IV fluid: wide open

  • No CP, but persistent ST elevation

    • IV tirofiban added

  • New Afib: rate controlled to 60’s

  • BCx growing G(+) cocci

    • Abx changed to vancomycin

  • LP not done

  • Line removed after HD


HD # 3-4

  • Clinically improving

  • Tn < 1.50  21.8

  • Resolving EKG changes

  • Off dopamine, dobutamine, heparin, tirofiban

  • BCx: Staph aureus


HD #5-7

  • Two episodes of R sided seizure

    • Phenytoin started

  • Slurred speech, R sided weakness

  • Head CT

    • 2.3cm hematoma on L frontal region

  • Transthoracic echo

    • Probable vegetation vs thrombus on MV

  • Transfer to DHMC CCU


Medications on Transfer

  • ASA 81mg PO qd

  • Metoprolol 25mg PO bid

  • NTG paste

  • Vancomycin IV with HD

  • Rofecoxib

  • Fentanyl patch

  • Epogen


Physical Examination

  • 36.5 69 120/70 20 98% on 6L

  • Gen: Ill appearing, somnolent, mildly confused

  • HEENT: PERRL, EOMI, OP-dry, clear

  • Neck: JVP-7cm, no LAD, supple

  • Cor:, RRR, no R/G, I-II/VI SEM on LSB

  • Lung: Slight bibasilar crackles

  • Abd: Soft, nontender, no HSM, active BS

  • Ext: Peripheral cyanosis, no C/E

  • Skin: No Janeway lesions/ Osler’s nodes/ splinter hemorrhage/ petechial lesions

  • Neuro: R sided weakness


Laboratory Data

10.3

13393 53

5.723 7.1

518

11.5

111

34.4

PTT: 28 PT: 16.2 INR: 1.5

CK: <20 Tn: 2.57 (<0.03)

ABG: 7.42/39/214 on 100%

CXR: Unremarkable

EKG: NSR, Q wave on III, nonspecific ST-T changes on precordial leads


Laboratory Data

  • Staph aureus sensitivity

    • PCN resistant, oxacillin sensitive

  • TTE:

    • EF 60%,

    • Mitral valve mass consistent with a vegetation on the atrial aspect of the posterior leaflet

    • Apical HK

    • Minimal MR


Assessment and Plan

  • Acute infective endocarditis complicated with septic emboli to heart and brain

  • Continue medical management

  • Abx changed to IV nafcillin

  • TEE

  • Continue ASA, beta blocker

  • No anticoagulation

  • Continue HD


HD #2-3

  • TEE:

    • Multiple vegetations on ant/post mitral leaflets on atrial side

    • Largest one 1.2 cm

    • No abscess, cavity or fistula

    • MV prolapse with trivial MR

  • Clinically improving

  • Transfer to floor


HD #4-10

  • Cyanotic R fingers

    • Doppler: Likely ulnar artery/palmar arch occlusion

    • Septic emboli most likely

    • Observation without any intervention

  • SOB with bibasilar crackles ½ up

    • Cor: 3/6 holosystolic murmur at apex

    • CXR: Pulmonary edema, small B pleural effusions

    • NTG drip

  • Repeat TTE

    • 2-3+ MR (worse than before)

  • BCx: NGTD


Surgery for Acute Endocarditis

  • Operative mortality 4%-22% (active NVE)

  • Potential indications include: CHF, perivalvular disease, uncontrolled infection, PVE, two (or one) episode of embolization, certain organisms

    • Pseudomonas, brucella, Coxiella burnetii, fungi

  • CHF strongest indication

    • 56-86% mortality w/o surgery vs. 11-35% with surgery

  • Hemodynamic status is the principal determinant of operative mortality

  • Optimal time for surgery is before hemodynamic instability or perivalvular spread

Mylokanis E, Calderwood S. Infective Endocarditis in Adults. NEJM 2001;18:1318-1330.

Reinhartz O, et. al. Timing of surgery in patients with acute infective endocarditis. Journal of Cardiovascular Surgery 1996;37:397-400.


HD #11-14

  • No complaints

  • 150’s/90’s 90s 20 Tmax : 38.5 91% on RA

    • Gen: NAD

    • Cor: JVP-7cm, RRR, 3/6 holosystolic murmur

    • Lung: Bibasilar crackles

    • Ext: No edema

    • Bld Cx: NGTD

  • A/P: Persistent fever with endocarditis

    • Rifampin added

    • TEE (show)


Transesophageal Echocardiogram


HD #11-14

  • No complaints

  • 150’s/90’s 90s 20 Tmax 38.5 91% on RA

    • Gen: NAD

    • Cor: JVP-7cm, RRR, 3/6 holosystolic murmur

    • Lung: Bibasilar crackles

    • Ext: No edema

    • Bld Cx: NGTD

  • A/P: Persistent fever with endocarditis

    • Rifampin added

    • TEE(show)

  • CT surgery consult  Proceed with surgery


HD #15-23

  • Operation

    • MV replacement (St. Jude)

    • Primary repair of posterior annular abscess

  • Transfer to CT ICU

    • Intubated, on pressor (milrinone)

  • Post Op TTE: Unremarkable

  • Clinically improving

    • Extubated on HD #17

    • Heparin, coumadin started

    • Transfer to 4E


HD #24

  • Fever (T 39.8)

    • Repeat Bld Cx sent

  • Micro data

    • MV Cx: No growth

    • MV abscess Cx: Few Candida parapsilosis

  • ID consult

    • Polymicrobial endocarditis?, secondary seeding of vegetation by one of the organisms?, coincidental Staph aureus bactermia?

  • Start fluconazole


Microbiologic Features of Native/Prosthetic Valve Endocarditis -ages 16 to 60-

Pathogen NVE PVE*

Approx. % of cases

Strep 45-65 1

Staph.aureus 30-40 20-24

Coag-neg staph 4-8 30-35

Gram-negatives 4-10 10-15

Fungi 1-3 5-10

Polymicrobial 1-2 2-4

* Early, < 60 days after procedure

Adapted from Mylokanis E, Calderwood S. Infective Endocarditis in Adults. NEJM 2001;18:1318-1330.


HD #25

  • Cross covering surgical housestaff called for fever (T 38.7), tachypnea (R 30-40)

    • Stat labs(CBC, lytes): Unremarkable

    • Blood cultures sent

  • Two hours later, pt in asystole

    • Epinephrine given, intubated

    • Palpable pulse with BP 160/80

    • EKG: Complete heart block

  • Transfer to ICU


HD #25

  • Assessment

    • Progression of fungal endocarditis involving conduction system most likely

  • Temporary transvenous pacing attempted but unsuccessful

  • Micro data from 27hrs prior

    • BCx: Budding yeast and yeast with pseudohyphae


HD #25

  • CT surgery

    • Very poor prognosis

    • Not a candidate for reoperation

  • Pt in complete heart block

  • Family Meeting

    • Comfort measures only

  • Pt extubated

  • 6 hrs later, pt died peacefully

  • BCx: Candida albicans

  • No post-mortem examination


TheNew England Journal of Medicine

February 14, 2002

USE OF A STAPHLOCOCCUS AUREUS CONJUGATE VACCINE IN PATIENTS RECEIVING HEMODIALYSIS

11

26

P = 0.02


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